A 39 year old male with cough and fever

5th April,2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

CHIEF COMPLAINTS :
Cough since 1 week
Fever since 1 week

HISTORY OF PRESENTING ILLNESS:
-Patient was apparently asymptomatic 1 week back then he developed cough which was initially associated with sputum,which was greenish in color later it became non productive,which was intially insidious in onset,gradually progressive and not associated with any aggravating or relieving factors.
-No h/o breathlessness,chest pain,hemoptysis, palpitations,indigestion,weight loss,night sweats.
-He also developed fever 1 week back which was insidious in onset, gradually progressive, intermittent,low grade and there is evening rise of temperature,it subsided with medication.
-He also complained of generalised weakness and insomnia.

PAST HISTORY:
Similar complaints one month back 
h/o diabetes mellitus since 7years and uses metformin
No h/o hypertension,asthma,epilepsy, coronary artery disease.

FAMILY HISTORY:
No similar complaints in the family 

PERSONAL HISTORY:
Sleep - not adequate
Appetite - decreased
Bowel and bladder movements - regular
Addictions - habit of chewing khaini since 20 yrs but stopped it from past 20 days
Drinks alcohol weekly once from past 10 yrs but stopped since 3 yrs

GENERAL EXAMINATION

Patient is conscious,coherent,cooperative and
he is malnourished.
Pallor - absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent

VITALS:
RR-16cpm
BP-130/90mmHg
PR-82bpm
SpO2-98%
Temperature-afebrile

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM:
URT -
Nose is normal
No polyp,DNS,pharyngeal congestion
LRT -
INSPECTION:
Chest is symmetrical
Movements of chest - symmetrical
Respiratory movements - rate:16cpm
                                  Type: abdominothoracic
Trachea appears to be central
No drooping of shoulders, intercostal fullness or retraction,crowding of ribs,winging of scapula
No visible sinuses,scars,dilated veins
PALPATION:
No local rise in temperature and no tenderness
Expansion of chest is equal on both sides in anterior,posterior and apical areas.
Trachea is central in position
Apex beat is felt in left 5th ICS 
TVF-vibrations decreased in mammary,axillary and interscapular areas
PERCUSSION:
Direct-Resonant
Indirect-dull at left interscapular and interaxillary areas
AUSCULTATION:
Breath sounds decreased at left axillary,mammary and interscapular areas.
CVS:
S1 and S2 heard 
No murmurs

CNS:
No focal neurological deficits

Per abdomen:
Soft and non tender
No organomegaly


PROVISIONAL DIAGNOSIS:
Left pleural effusion 


INVESTIGATIONS:

XRAY chest:
USG chest:



TREATMENT:
T Cefixime 200mg PO BD
T PAN D 40mg PO OD 
Syrup Grillinctus D 2tsp PO BD
T UDILIV 300mg PO BD





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